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Based on observations, staff interview and record review the facility failed to assure consistent appropriate hand hygiene practices by staff, in accordance with their Policy & Procedure, to prevent the transmission of disease. Findings include:

Per review, conducted on the afternoon of 12/29/11, the facility's Hand Hygiene Policy, dated 6/14/11, stated; Indications for Hand Hygiene, #5) "After removing sterile or non sterile gloves".

1). During observation of direct patient care, at 10:00 AM on 12/29/11, the physician providing care for Patient #1 did not wash or sanitize his/her hands following a procedure performed by him/her. After completing a colonoscopy procedure the physician removed his/her gloves, and, without washing or sanitizing hands donned a lab coat, handled the patient chart and touched the door handle when leaving 3:the procedure room. During interview, immediately following the observation, Nurse #1 confirmed the lack of hand hygiene by the physician.
2). During observation in the ED (Emergency Department), at 3:18 PM on the afternoon of 12/28/11, a staff member failed to wash or sanitize his/her hands after providing care to Patient #2. Following a blood draw procedure on the patient, in room #4, which contained a working sink, Lab Tech #1 removed his/her gloves and, without washing hands, picked up the lab tray containing lab specimens and left the patient room. Although there was a container of hand sanitizer attached to the wall directly outside the door of the room the Lab Tech did not sanitize his/her hands and continued to leave the ED.

During interview, at 12:58 PM on 12/29/11, the Infection Control Practitioner (ICP) confirmed the Policy's expected hand hygiene practice following removal of gloves. The ICP further stated that although a new campaign, focused on promoting hand hygiene for staff and patients, had recently been implemented, there is currently no formal process for monitoring and evaluating hand hygiene practices among staff to assure they are consistent with the facility's Policy & Procedure.